Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 1986210 | IL |
NPI | 1073031019 |
---|---|
Provider Name | Mark Daniel Moore |
First Address | Crescent City, IL 60928-8092 |
Second Address | Crescent City, IL 60928-8092 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2017 |
Last Update Date | 20/06/2018 |